JAまごころ会入会費

¥5,000 （税込）

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入会者情報入力

姓 *

姓を入力して下さい

ふりがな *

姓（ふりがな）を入力して下さい

名 *

名を入力して下さい

ふりがな *

名（ふりがな）を入力して下さい

性別 *

男性 女性

誕生年 *

誕生年を選択して下さい1922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000生まれた年を選択して下さい

誕生月 *

誕生月を選択して下さい1月2月3月4月5月6月7月8月9月10月11月12月生まれた月を選択して下さい

誕生日 *

誕生日を選択して下さい1日2日3日4日5日6日7日8日9日10日11日12日13日14日15日16日17日18日19日20日21日22日23日24日25日26日27日28日29日30日31日生まれた日を選択して下さい

郵便番号 *

郵便番号を入力して下さい

都道府県 *

北海道青森県秋田県岩手県宮城県山形県福島県茨城県栃木県群馬県埼玉県千葉県神奈川県東京都山梨県新潟県長野県富山県石川県福井県静岡県愛知県三重県岐阜県大阪府京都府滋賀県奈良県和歌山県兵庫県岡山県広島県山口県鳥取県島根県香川県徳島県愛媛県高知県福岡県佐賀県長崎県熊本県大分県宮崎県鹿児島県沖縄県

市区町村 *

市区町村を入力して下さい

番地 *	番地を入力して下さい

建物号室

自宅電話番号 *

自宅電話番号を入力して下さい

携帯電話番号

宗派入力

宗派

仏式 神式 その他

宗

派

寺・院

住職

神社

宮司

その他

JAまごころ会入会費個

カートに追加
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